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General and Preoperative Care

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Chapter 4 : General and Preoperative Care

General and Preoperative Care of the Patient arrow_upward

  • Preoperative care is the preparation and management of a patient prior to surgery.
  • It includes both physical and psychological preparation.
  • Preoperative care involves many components, and may be done the day before surgery in the hospital, or during the weeks before surgery on an outpatient basis.
  • The anticipated outcome of pre-operative care is a patient who is informed about the surgical course, and copes with it successfully.
  • The goal is to decrease complications and promote recovery.

  • Purpose arrow_upward

  • Patients who are physically and psychologically prepared for surgery tend to have better surgical outcomes.
  • Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or a form of major surgery.

  • Physical Preparation arrow_upward

  • Physical preparation may consist of a complete medical history and physical exam, including the patient's surgical and anesthesia background.
  • Laboratory tests may include:
    • Complete blood counts should be performed on all patients.
    • Serum Electrolytes should be done on all patients over 40 year.
    • A Coagulation Screen if there is a history of bleeding disorder or on anticoagulation therapy.
    • An Electrocardiogram should be done on all patients over 40year.
    • A Chest x-ray is required in all patients with symptomatic pulmonary disease or underlying malignancy.
    • Urinalysis is required in all patients.
  • The patient should also provide a list of all medications, vitamins, and herbal or food supplements that he or she uses.

  • Psychological Preparation arrow_upward

  • Psychological preparation can be especially beneficial for patients who are critically ill, or who are having a high-risk procedure.
  • The family needs to be included in psychological preoperative care.
  • Patients and families who are prepared psychologically tend to cope better with the patient's postoperative course.
    • Preparation leads to superior outcomes since the goals of recovery are known ahead of time, and the patient is able to manage post-operative pain more effectively.

    Informed Consent arrow_upward

  • The patient's or guardian's written consent for the surgery is a vital portion of preoperative care.
  • Informed consent supports the rights of a patient to make decisions about his or her own healthcare.
  • By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with the other treatment options.
  • Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent.

  • Pre-operative Teaching arrow_upward

  • Preoperative teaching includes instruction about:
    • The Preoperative Period
    • The Surgery itself
    • The Postoperative Period
  • Instruction about the preoperative period deals primarily with:
    • The arrival time
    • Where the patient should go on the day of surgery
    • How to prepare for surgery
  • Instruction about the surgery itself includes:
    • Informing the patient about what will be done during the surgery.
    • How long the procedure is expected to take.
  • Pre-operative instruction should include information about the pain management method that they will utilize post-operatively.

  • Nutrition for Patients arrow_upward

  • Nutrients are the substances that are not synthesized in the body in sufficient amounts and therefore must be supplied by the diet.
  • A fundamental goal of nutritional support is to meet the energy requirements for:
    • Metabolic Processes
    • Core Temperature Maintenance
    • Tissue Repair
  • Nutritional requirements:
    • Energy giving (carbohydrates; proteins & fat)
    • Vitamins
    • Mineral
    • Water

    Preoperative Nutritional Support arrow_upward

  • Preoperative refeeding can reduce the risk of postoperative complications in malnourished patients but provides no benefit to healthy, well-nourished surgical patients.
  • Significant reductions in morbidity with the use of preoperative nutritional support are seen only in patients with severe under nutrition.
  • Preoperative nutritional support should be considered for patients who are below the fifth percentile in weight for age or who have a recent 10% weight loss.

  • Postoperative Nutritional Support arrow_upward

  • In the fasting postoperative patient, skeletal muscle protein is mobilized to provide protein for acute-phase reactants and wound healing.
  • Energy is supplied mainly by mobilizing fat stores.

  • Routes of Administration arrow_upward

  • Following are the routes of administration for the surgical patients depending on the situation of the patient:
    • Enteral.
    • Parenteral.

    Enteral Nutrition arrow_upward

  • The enteric route is safer and cheaper and is preferred whenever nutritional support is required, if the GI tract is functional.
  • This type of nutrition can be started 6–8 hour following surgery and has a few risks such as:
    • Risk of aspiration.
    • Tendency to cause abdominal cramps.
    • Bloating.
  • Adequate nutrition can be provided in liquid or semisolid form via nasogastric tubes even in patients who are unable to chew or swallow.
  • Enteral nutrition is preferred over parenteral nutrition as its mode of administration is not very invasive and has fewer chances of inducing infection.
  • Enteral feeding is considered helpful in:
    • Radiation Therapy.
    • Mild Chemotherapy.
    • Massive Small Bowel Resection.
    • Liver failure and severe Renal Dysfunction.

    Complications of Enteral Feeding:

  • Malposition and blockage of tube.
  • Gastroesophageal reflux.
  • Feed intolerance.

  • Parenteral Nutrition arrow_upward

  • Parenteral nutrition involves the continuous infusion of a hyperosmolar solution containing necessary nutrients through an indwelling catheter inserted into the superior vena cava.
  • Patients who receive enriched parenteral nutrition have demonstrated better and faster recovery rates and lower complication and morbidity rates.
  • Total Parenteral Nutrition (TPN) is indicated when:
    • The GI tract is not accessible or not functioning.
    • When gut rest is needed.
    • Oral or enteral feeding does not meet the patient’s nutritional needs.
  • TPN is often preferred because critically ill patients require a lot of nutrients and cannot tolerate large fluid infusions.
  • TPN solutions are designed to include all the basic nutrients that patients require for maintenance of:
    • Normal body composition.
    • Growth.
    • Tissue repair.

    Complications of Parenteral Nutrition

  • Technical Complications include:
    • Sepsis.
    • Pneumothorax.
    • Hemothorax.
    • Hydrothorax.
    • Air embolism.
  • Metabolic Complications include:
    • Hyperglycemia.
    • Carbon dioxide retention.
    • Respiratory insufficiency.

    Thank You from Kimavi arrow_upward

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